Step therapy in the states

| Patrick Stone

You finally found the right biologic for one of your psoriasis or psoriatic arthritis patients. Your patient is thrilled with the improvement in her disease, and as a result, her satisfaction and adherence has skyrocketed.

Then she gets a different insurance plan. When she goes to fill her prescription, she’s told that her new insurer requires her to first try and fail a different treatment before she can get the one that works best for her.                                                                                                                                                                                           

Sound familiar? This practice, when insurers require patients to try other medications first before “stepping up” to other drugs, is known as step therapy.

As insurance companies continue to compete for business in the exchange and private markets, the pressure is on for them to offer plans with low premiums. Because insurers have limited tools available to drive down premiums, the use of tools like step therapy has increased.

The National Psoriasis Foundation is working hard to overcome the restrictions step therapy places on you and your patients. Our priority is ensuring that the patient and provider relationship is honored. 

Step therapy protections: Coming soon to a state near you

NPF’s state government relations team has become a leader on the policy discussions taking place on step therapy. Thanks to our work on behalf of—and with—patients and providers, a half dozen states, including Illinois, Indiana, Missouri and New York, have passed step therapy legislation providing increased patient protections. To date, nearly a dozen more states are considering it. 

The map below provides an overview of which states have step therapy legislation that is enacted or pending to date:

Our goal through this legislation, which is nearly identical in each state, is to provide you and your patients a clear path to being granted a step therapy exception. The bills require that step therapy protocols be based on sound clinical evidence, not just cost, and enumerate several instances where an exception to step therapy must be granted by the insurer.

In addition, the bills significantly cut down the amount of time that an appeal takes. Currently, an exception request can take over a month. Our legislation seeks to reduce that down to three business days. In an emergency, it can be cut down to less than 24 hours. 

My state passed step therapy legislation. Now what?

These protections put the power of practicing medicine back in the hands of the physician.

The legislation adds transparency to the step therapy process and makes it easier for doctors to request an exception to the usual step therapy requirement for situations when a patient has already tried and failed the required therapy, or when the patient has already experienced an adverse event on that treatment.

Under the new law, doctors now have a uniform appeal process they can follow similar to the process they already follow to request prior authorization for a prescription drug.

The protections are intended to save you time and enable you to deliver treatment success to your patients. But they are complex.

That’s why NPF is teaching doctors and patients what to expect from the new legislation. In states where the bills have passed, we’re developing webinars to educate patients and doctors on the bills and how they can best take advantage of the new protections.

During these webinars, you’ll get an overview of the bill and its protections, and you’ll hear stories from health care providers and their staff about their experiences with the appeal process. You’ll understand the legal ins and outs of the legislation and get tips from patient advocates and providers on how  to best utilize these protections for your patients.

As we enter the 2017 state legislative cycle, NPF will begin offering these webinars in states where step therapy legislation has passed. We’ll be sending out notices about upcoming webinars through our emails. If you’d like more information, email Patrick Stone, NPF’s associate director of state government relations.

What else is NPF doing to help my patients get the treatments I prescribe?

In the meantime, your patients can get their questions about insurance and medication answered any time through our Patient Navigation Center. From denied insurance claims to complicated paperwork, we understand the obstacles that stand between patients and the right treatments.

Our Patient Navigators can help your patients save on prescriptions, apply for financial assistance programs and find an insurance plan that best suits their needs.

For more information on services the Patient Navigation Center offers to providers, click here.

Do you have a story about step therapy? Do you want to let legislators know how step therapy affects your practice? Email Patrick Stone [email protected] or keep an eye on your inbox for opportunities to take action. 



Driving discovery, creating community

For more than 50 years, we’ve been driving efforts to cure psoriatic disease and improve the lives of those affected. But there’s still plenty to do! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funds to support research by joining Team NPF, where you can walk, run, cycle, play bingo or create your own fundraising event. If you or someone you love needs free, personalized support for living a healthier life with psoriatic disease, contact our Patient Navigation Center. And keep the National Psoriasis Foundation going strong by making a donation today. Together, we will find a cure.

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